Psychiatry and Religion

This chapter examines the changing relations between psychiatry and religion. It examines views of the causes and cures of mental illness in some religious traditions. Some psychiatric views of religion and its place in mental illness are described. Current psychiatric practice is examined, including areas such as ascertaining the patient’s religious history, understanding cultural variations in religious behaviour, and religious barriers to seeking psychiatric help. There is a brief overview of attempts to alleviate problems, including an outline of steps taken by professional organisations to accommodate to the issues raised for psychiatrists by religious factors.

Buddhism

Christianity

Diagnosis

DSM

Help-seeking

Hinduism

Islam

Judaism

Meditation

Psychiatry

Religion

Sin

Spirituality

Stigma

The relationship between psychiatry and religion has been difficult and variable, and has developed over the two centuries of psychiatry’s official existence.

Psychiatry is the branch of medicine dealing with mental, emotional or behavioural disorders. (Merriam-Webster 2013) For present purposes it is significant that “psych” is a stem of Greek origin often translated as “soul” (“-iatry” refers to medical treatment). The term was first used in the early nineteenth century: this timing is significant since it reflects a developing medical interest in insanity, for which earlier there had been little or no treatment other than confinement under more or less (usually less) humane conditions. Current psychiatric views on the causes and cures of psychiatric disorder involve a huge range of detailed suggestions involving biological, social and psychological levels of analysis.

Religion has many definitions and methods of assessment (e.g. Brown 1987, Hill and Hood 1999, Loewenthal 2000). Major religions agree on the existence of non-material (i.e.spiritual) reality, and see the purpose of life as increasing harmony in the world by doing good and avoiding evil. Monotheistic religions hold that the source of existence (i.e. G-d) is the source of moral directives. Religious traditions offer a range of views on the causes and cures of psychiatric disorders, and these often appear sharply different from the views offered in psychiatry, focussing chiefly on spiritual factors.

How have psychiatry and religion related to each other?

There has been a generally fraught history. Foskett (1996) describes it as a history of discord. This chapter will first examine how insanity and it causes and cures have been seen in selected religious traditions, and will then look at how religion has been seen through some psychiatric eyes. Finally, the current state of the relations between psychiatry and religion will be viewed, along with an overview of attempts to alleviate some of the problems.

Beliefs about mental illness in different religious traditions.

Psychiatry developed in the Western world at a time when Christianity was the dominant religion in Europe, the United States and numerous colonial countries. Twentieth-century social and other changes have increased the numbers of Muslims, Jews, Hindus, Buddhists and members of other (including new) religious movements in western countries. Religions have many different forms or denominations, with considerable variations in beliefs and practices. All have been and are in a constant process of development and change.

Christianity: The doctrine of the trinity (Father, Son and Holy Spirit) is central to Christianity, as is the idea that the death of Jesus atoned for the sins of humanity. Important for mental health are Christian dogmas regarding sin. Suffering is the result of sin. Salvation involves justification, the removal of sin and its effects by one or more of repentance, penance, indulgence, confession, absolution and forgiveness. (e.g. Stagg 1962). These doctrines may be associated with pejorative views of sufferers from illness and misfortune, including sufferers from mental illness (Lerner 1980). It has been reported that Christians suffering from mental illness may be made to feel that their illness and suffering are the result of their sins (Stanford 2007). However, although suffering is not seen as a desirable end in itself, it can be seen more positively seen as a gateway to renewal and rebirth. Some historians of psychiatry have suggested that a widespread Christian view of mental illness, particularly during the fifteenth to seventeenth centuries, is that it is the result of demonic possession (Lipsedge 1996).

Islam: In Arabic, Islam means submission to the will of G-d. There is a clear core of religious duties, including belief in G-d and the prophets, prayer, giving away a proportion of one's goods, fasting in the month of Ramadan, and pilgrimage. In Islam, sin results from pride and self-sufficiency, leading to forgetfulness of divine unity and wrong moral/religious choices. An important Islamic view of the mentally ill is that they are the 'afflicted of Allah'. Some contemporary observers have noted that Jinn possession may be seen among Muslims as a cause of insanity (Dein et al., 2008) It is noteworthy that the earliest recorded psychiatric institutions - established over a thousand years ago - were in Moslem countries (Loewenthal 1994).

Judaism: Judaism is the oldest of the monotheistic religions, and a central tenet is the belief in the unity of G-d. There are many religious commandments, governing more or less the total life-style, and practised to varying extents: diet, sexual behaviour, work, business ethics and worship are among the areas of religious law. Madness is mentioned in the Jewish biblical texts without clear attribution of its causes, though there is some suggestion of a distinction between spirit possession and insanity. Later Jewish sources of the Talmudic period distinguish describe a range of psychiatric conditions resembling those found in contemporary practice (Miller, 1972). The legal status of the insane with regard to their civil and religious obligations is a matter of discussion in works on Jewish law: for example whether the insane are valid witnesses (probably not) and whether insanity is grounds for divorce (probably yes, but the situation is complicated). The Hebrew term for madness (choli nefesh) means sickness of the soul, and there are rabbinic figures in Jewish communities who carry out counselling and therapeutic activities based on views that the rectification of spiritual-moral failings - such as pride - will improve mental health. Misfortune is seen as warning to the individual to improve, and as a divine test of the individual; also as part of an overall divine plan in which everything is for the ultimate good.

Hinduism: Hinduism is the religion of India, and has many varied manifestations, tolerating a wide range of beliefs and practices. There is an underlying monotheism, with lesser divinities as aspects of one G-d. This infinite principle is truly the sole reality and the ultimate cause and goal. There is a religiously sanctioned caste system, said to be in some decline. Religious worship is carried out in a shrine in the home, usually by women. Transmigration of souls and reincarnation are important aspects of Hindu belief. The ultimate goal is infinity (G-d), and the attainment of this goal is prevented by karma (rebirth); following death and a sojourn in heaven or hell, the soul is reborn into a physical form determined by actions in the previous incarnation. This process of rebirth (samsara) is seen as potentially endless, and not progressive in any way. Misfortunes are an aspect of karma, and can be escaped by marga - emancipation. Of which the main types are duty, knowledge and devotion. Bhugra (1996) has described the importance of Ayurvedic medicine in the treatment of mental illness in India, and in one study, nearly half the psychiatric patients (81% Hindu) questioned had consulted a religious healer (Campion and Bhugra 1997). Craissati (1990) states that mental illness in India carries a major stigma, and that consulting a psychiatrist and going to hospital are regarded as last and desperate resorts. In rural communities, where most of India's population (80%) live, tolerance for bizarre behaviour is very high. Psychotic symptoms are seen as the result of spirit possession, black magic, or as the consequences of a previous life. A mentally ill person will be taken to a healer within the community. If this is not successful, it is regarded as the family's duty to bear with the person. Craissati says that patients are only brought to the 'Western' psychiatric hospital where there is serious threat to the norms governing family life and sexual behaviour.

Buddhism: The fundamental teaching of Buddhism involves viewing an attachment to the world and its pleasures as the cause of pain. Self-mortification is also an extreme to be avoided; the founder of Buddhism, Gautama Buddha taught the 'middle path'. Life is fundamentally a process of suffering. As in Hinduism, transmigration and rebirth are not seen as progressive, and the central aim of religious belief and practice is to liberate. The 8-fold path to freedom from suffering includes right thought, speech, action and mental attitudes. These lead to the cessation of pain, and to enlightenment, and Nirvana (wherein the soul will not be reborn to further suffering). Buddhist psychology is popular in the West (Valentine, 1989). It is suggested that religious practices and thoughts will promote the relief of many if not all forms of mental illness and forms of meditation have been incorporated into contemporary cognitive-behaviour therapy (Segal et al., 2002).

Overall religious views on mental illness. This summary of views from selected religious traditions suggests some similarities across religions can be seen. Beliefs about mental illness and its treatment may be tied to beliefs about sin and suffering, though malign spiritual beings may also be implicated. Mental illnesses are seen to result from separation from the divine or possession by evil. Psychiatry may be mistrusted, except as a last resort, and 'folk' healers may employ a wide range of symbolically-loaded rituals and cognitive-behavioural techniques designed to facilitate spiritual healing , leading (hopefully) to an improvement in mental health.

Some empirical work indicates that the views of religiously-active people on psychiatric disorder will reflect religiously –taught views – although in practice most of those questioned have a foot in both cultures, supporting both contemporary views on stress and biological factors, while simultaneously acknowledging the importance of spiritual factors (Cinnirella and Loewenthal 1999, , Leavey et al., 2007, Dura-Vila et al., 2011; Bayes and Loewenthal 2013). Sin however is not a popular explanation among religious laity. In the western world, the older generation of minority group immigrants may see orthodox health services and psychiatry as having little to offer. For example:

“. . . in the older generation if you’ve got a mental illness, they think you’ve got a bad spirit in you (and) that’s why you hear all these voices and that’s why this person (voice) is telling you to do things you’ve been doing.. .they’ll just think, ‘oh, go to a holy person

and they will cure you’ (Hindu informant, quoted in Cinnirella and Loewenthal 1999).

Beliefs about religion among psychiatrists

Attitudes to psychiatric disorder change with time. In Western Europe and the USA, for example, one view of disorder up until the eighteenth century was that it was caused by demonic possession, perhaps a result of the preoccupation with witchcraft from the fifteenth century onwards, although stress was often seen as an important factor (Lipsedge 1996). Fear, neglect, isolation and ill-treatment of the mentally-ill was socially and religiously-sanctioned. Bedlam in London and the Bicetre in Paris chained up their unruly inmates. The aim of such institutions was simply to isolate the unruly from society. Sometimes, the insane would be auctioned off to be 'cared for' (used as slaves) by farmers (Loewenthal, 1994). By the nineteenth century, medical opinion calling for more humane treatments was growing. Tuke, a Quaker merchant, founded the York retreat at the end of the eighteenth century. Here, prayer and religious devotion were seen as central to healing. Pinel and Connolly pushed the movement to see the insane as individuals suffering from sickness, requiring treatment. Pinel abolished chains from the Bicetre, and in the 1840s, Dorothea Dix began a campaign to improve conditions in insane institutions in the United States. Religious practice was often (but not always) acknowledged as an important features of psychiatric care. In Britain the Lunacy Act of 1890 ordered a church in every asylum; inmates had to attend twice a day. In France, by contrast, Pinel would not allow the mentally ill to be exposed to religious practices: these might encourage delusions and hallucinations. Psychiatric hospitals in most western countries nowadays normally maintain a chaplaincy service. This does not always cater for minority religions, chaplains are sometimes unpaid, and are normally overloaded.

Major changes in psychiatric thinking include the introduction of psychoanalysis in the early twentieth century, the anti-medical-model movement, the introduction of cognitive-behavioural and other “talk” therapies in the latter part of the century, as well as the enormous growth in the neuroscientific and biochemical understanding of psychiatric disorder.

Psychoanalysis, spearheaded by Freud, carried as part of its baggage the general idea that religion was unnecessary and damaging to mental health. Four of Freud’s books (1927, 1928, 1930, 1939) analysed religion, reflecting and helping to form a growing zeitgeist which viewed religion as a collection of primitive superstitions, neurotic rituals, and an illusion, comforting at one time, but no longer necessary in these enlightened times. Freud described religion as a "universal obsessional neurosis", which has succeeded because it spares the individual the labour of developing his or her own neurosis. Freud described G-d as a projection of the image of the father, and "a system of wishful illusions together with a disavowal of reality, such as we find nowhere else but in amentia" (Freud 1907, 1927).

Although Bettelheim (1983) attempted to see Freud’s ventures as essentially spiritual in nature, and it is certainly true that religion was a major focus of Freud’s attentions, Freud’s writing has epitomised negative twentieth-century views on the role of religion in mental health. Other twentieth-century writers have contributed to this zeitgeist, perhaps most notably Albert Ellis in his earlier writings (e.g. Ellis, 1958). He was an outspoken participation in public debate, arguing that the influence of religion was to increase guilt and anxiety over wrongdoing: religion harmed mental well-being. His views on religion became more benign in later life (Ellis, 2004).

In contrast to Freud, Jung (1958) saw the psychological quest for wholeness and healing as a journey which is essentially spiritual . Jung’s views were developed by others during the twentieth century, and were welcomed by those responsible for training clergy in pastoral work.

Contrary to Freud’s and Ellis’s claims, thousands of pieces of empirical work have by now shown that religiosity is normally associated with better mental health (Koenig et al., 2012). Nevertheless there are still some lacunae: for example the suggestion that religious ritual is compelled by anxiety has meant that very limited attention has as yet been given to the positive experiences and mental health benefits of the many religious rituals engaged in (Dein and Loewenthal, 2013)

The existence of a chaplaincy service can be a compelling reason for psychiatrists to feel that religious issues are for the chaplains to deal with: religious issues are outside the psychiatrist’s competence, so are ignored (Neeleman and Persaud 1995). Nevertheless, possibly related to the rise in popularity of the concept of spirituality, alongside the growing volume of work suggesting the importance of religious and spiritual factors in mental health, psychiatrists have taken a growing interest in religious and spiritual issues (Bhugra 1996; Dein et al., 2011). Spirituality has been suggested as a possible contemporary alternative to religion (Heelas and Woodhead 2005, King and Leavey 2010, Dein et al., 2012), and contemporary psychiatric and social-scientific writing on mental health often feature discussions on its relations with spirituality as well as or instead of its relations with religion (e.g. Cook et al., 2009, Lewis et al., 2011, Paloutsian and Park 2013, Pargament et al., 2013).

Views and practices about the place of religion in psychiatric theory practice have changed over the nineteenth and twentieth centuries. Generally there have been growing numbers of attempts to integrate the role of religion into the understanding the patient’s psychiatric history, and to acknowledge the role of religion in treatments planning. We turn now to look at some specific aspects of contemporary practice.

Religion in contemporary psychiatric practice

Some early signs of serious psychiatric interest in the role of religion in psychiatric care included conferences and publications dating from the 1990s (e.g. Bhugra 1996, Loewenthal, 1994,Littlewood and Lipsedge 1997, Greenberg and Witztum 2001, Koenig et al., 2001). Some of this work was culturally limited (to practice in Christian-based western cultures), but some emphasised the importance of acknowledging the importance of cultural factors and variations in the roles played by religion in different cultural-religious groups.

There have been a growing number of claims that knowing the patient’s religious history is important in psychiatric practice. Empirical work has suggested that many patients would welcome enquiries from mental health professionals about the place of religious and spiritual issues in their psychological battles, and there are useful published guidelines about how this may be done (Pargament 2007, Koenig 2008, Culliford and Eagger 2009). Some of these suggestions have proved controversial . Notably, Koenig (2008) suggested that psychiatrists should take a spiritual history, support healthy religious beliefs and challenge unhealthy beliefs, pray with patients (in “highly selected cases”), and work in liaison with trained clergy. The suggestions that psychiatrists are able to pass judgement on the healthiness of different religious beliefs, and on the appropriateness of praying with their patients has aroused significant concerns (Cook et al., 2011; Poole and Higgo 2011)

Barriers to seeking professional help for psychiatric problems are of major concern. These barriers often involve religious factors. Delay in help-seeking can involve significant worsening of psychiatric illness.

These barriers chiefly involve fears of misjudgement, concerns about religiously inappropriate treatment and fears of stigmatisation.

Psychiatrist are less likely to be religiously active than their clients and this can heighten clients’ mistrust (Bergin and Jensen 1990, Cook 2011), involving fears of professional misjudgement of religious behaviours, of which there are many examples (Loewenthal 2007). Religious practices may give the appearance of bizarre behaviour, which may be interpreted as mad, or unreasonable, or neurotic, or selfish, or heartless. For example:

“The concept of a 'good death' is very important to Hindus. A good death involves making spiritual preparation for the soul leaving the body, and settling ones worldly affairs. One of the religious customs which many Hindus feel should be observed is that when death occurs, the person should be lying on the ground, preferably in a certain orientation with respect to the north. This has led to many difficulties with Hindu patients in British hospitals. Many will make efforts to be at home if and when they feel the end is approaching. When the dying person is in hospital, he or she may manage to climb or roll out of their bed in order to be on the floor for the moment of death. This obviously requires tremendous effort, but it is often wasted, especially if there are no relatives or friends to explain the meaning of the behaviour. The horrified nurses rush over to replace the nearly moribund patient safely back in bed - much to his/ her distress. Their sufferings are increased when their pleas and protestations are not effective, and every time they manage to assume the religiously proper position on the floor, they are firmly bundled back onto the bed. The first time the patient appeared on the floor, the nurses might have thought it was a mishap of some kind, but after the third or fourth time, they think s/he is deluded, mad, or deliberately being a nuisance” (Firth 1997).

The fear of misjudgement constitutes a barrier to the seeking of professional help for mental health difficulties. Judgment biases have sometimes been demonstrated empirically. For example Yossifova and Loewenthal ‘s (1999) vignette study involved clinical judgments of case histories identical in every details except that some patients were described as religiously active, others not. Religious people were more likely to be seen as suffering from obsessive illness than non-religious people with the same symptoms.

A further barrier is the fear that treatment recommendations may be seen as religiously inappropriate. Some religious groups will avoid psychotherapy if there is a risk of physical contact between the sexes (Loewenthal, 2006). Those from collectivist religious-cultural groups may feel that professional suggestions to alleviate distress and psychiatric symptoms by leaving abusive relationships, may be rejected on the grounds that family and community solidarity is more important and religiously valuable than individual well-being (Gilbert et al., 2004; Loewenthal, 2013).

An associated, stronger barrier is the extent to which mental illness is stigmatised, and this effect may be particularly marked in tightly-knit social groups, of which religious groups are an outstanding examples:

• “Our people do not go to the doctor (when depressed), in fact they hide it, because they think that if people know about it they will not accept them and they’ll be laughed at and would be completely shut off because there is this prejudice”(Muslim, in Cinnirella and Loewenthal 1999).
• “The one thing Black people hate is for anybody to find out there is any form of mental illness in their families…what they try to do is shut that person away and deal with it by themselves as opposed to going through all the networks and being exposed.” (Black Christian, in Cinnirella and Loewenthal).
• “I wonder what type of families need this (kind of help)? Is it just those who can’t cope? I might feel ashamed to ask for such help”(Orthodox Jewish, in Loewenthal and Brooke-Rogers, 2004).

Examples of recent work in the field give further indications of some of the issues preoccupying investigators. Regan et al (2013) systematically reviewed the literature showing how religion influences pathways into care for dementia patients in minority ethnic groups. The main conclusions were that religion hinders access to the traditional care for dementia, which may increase the burden on relatives and other carers . For example an African American woman, a Pentecostal Christian, filled with the Holy Ghost in a nursing home, became excitable, and fainted. Her behaviour was misinterpreted as pathological and she was unnecessarily restrained. Reports of such incidents lead to fear of misunderstanding, and delay care-seeking. However Regan et al conclude that religion, as in other areas, assists in carers in positive coping.

Another recent study (Dura-Vila et al., 2013) examined the accounts of coping by contemplative nuns who had been sexually abused by priests. Trauma was “transformed into a symbolic religious narrative” in lengthy processes of solitary introspection involving forgiveness, sacrifice and salvation, which reshaped their core beliefs and allowed the abused women to regain and sense of spiritual well-being: for example the post-abuse contemplation eventually led to an increase in the sense of spiritual purity. This work contributes to the growing literature on post-traumatic spiritual growth, and on positive psychology, important elements in the psychiatry-religion interface.

Improving practice

From within religious groups, clients see therapists from their own religious group as more likely to understand them. However they can be worried that this makes it more likely that their problems will become known in the group (Cinnirella and Loewenthal 1999; Loewenthal and Rogers, 2004). One solution is the provision of own-group help in discreet locations, in which the client feels less concern about being seen by people they know. Further, the client may select an own-group helper belonging to a social sub-group different from their own. Attempts have been made to train own-group professionals, particularly in counselling skills – clients may still have concerns about the professionalism and confidentiality, but on the whole such training schemes have worked well and have filled a gap in service provision (Loewenthal & Rogers).

Attempts to improve awareness of mental health issues, and of ways to manage them, include dissemination of information via various media including the internet (for example the American Psychiatric Association website (2013) offers a wide range of mental health information for the lay public, as does the UK Royal College of Psychiatrists website (2013), offering “Mental health information for all”. These attempts may help to reduce the strength of some religiously-related barriers to professional help-seeking.

Professional organisations have been active in improving training to increase awareness and knowledge of norms of relevant religious behaviour. An important step taken by the American Psychiatric Association was to introduce the V code into the fourth edition of its internationally-used diagnostic manual; this was a significant attempt to depathologise religious behaviour, and to alert professionals to the possibilities and methods of distinguish normative from pathological religious behaviour (Scott et al., 2003, Dein et al., 2011). Significant books contribute to awareness of this issue (e.g. Bhugra 1996, Peteet et al., 2011). The UK Royal College of Psychiatrists Special Interest Group focussing in spiritual issues in psychiatry, the UK National Spirituality and Mental health Forum, and other bodies, organise conferences and publications (Royal College of Psychiatrists 2013a, National Spirituality and Mental Health Forum 2013), with significant focus on the importance of religious issues in diagnosis and treatment. There are several academic journals featuring research and thinking on the psychiatry-religion interface (notably Mental Health Religion and Culture, Transcultural Psychiatry, The International Journal of Social Psychiatry). In related disciplines, Division 36 of the American Psychological Association focuses on the psychology-religion interface, and several journals contribute to the understanding of social-scientific perspectives on mental health issues (for example Anthropology and Medicine, Journal of Religion and Health, International journal for the Psychology of Religion, Social Science and Medicine).

There has been a useful growth in the volume of work designed to improve understanding of the interface between psychiatry and religion, for both professionals and lay people. There is scope for more, perhaps particularly for further attempts to improve understanding of mental disorder among lay people, to reduce the stigma associated with this disorder, to reduce the negative impact of religious factors and to allow scope for the positive roles that can be played by religion in coping with psychiatric disorders.

See also:

21030. Diagnostic Processes in Clinical Psychology and Psychotherapy

21047. Concepts and Methods of Cognitive Therapies

21062. Psychoanalytic psychotherapy

21072. Counseling and Psychotherapy: Ethnic and Cultural Differences